Carlo Marcucci

Background/Objectives: Anemia is a common condition in cardiac surgery and is strongly associated with adverse outcomes, including higher transfusion requirements, increased morbidity, and prolonged hospital stay. Enhanced Recovery After Surgery (ERAS) and Patient Blood Management (PBM) are both multimodal strategies designed to improve perioperative care. This study evaluates the impact of integrating ERAS and PBM with preoperative anemia management into a single standardized pathway in elective cardiac surgery. Methods: We conducted a retrospective, single-center before–after study at Lausanne University Hospital, comparing a pre-ERAS cohort (2019) with a prospective cohort managed under the ERAS–PBM pathway (May 2023–November 2024). The ERAS–PBM pathway included systematic preoperative anemia screening and treatment, reinforcement of adherence to existing restrictive transfusion thresholds, optimized blood conservation techniques, and standardized perioperative care bundles coordinated by a dedicated ERAS nurse. The primary outcome was the rate of red blood cell (RBC) transfusions during hospitalization. Secondary outcomes included overall transfusion rates, hemoglobin levels, complications, and length of stay. Results: A total of 391 patients were included (ERAS, n = 229; pre-ERAS, n = 162). RBC transfusion rates were significantly lower in the ERAS group (23.6% vs. 38.9%, p = 0.0012), with a reduction in the number of units per patient (p = 0.0005). Hemoglobin at admission was higher in the ERAS cohort (139.5 vs. 134 g/L, p = 0.0009). Overall complication rates decreased (46.3% vs. 66.7%, p < 0.0001), including major adverse cardiovascular events and pulmonary complications. Hospital stay was shorter (9 vs. 12 days, p < 0.0001), as was mechanical ventilation time (0 vs. 2.1 h, p < 0.0001). Anemic patients at admission were more transfused (39.3% vs. 18.6%, p = 0.002). Within the ERAS group, RBC transfusion was associated with higher rates of selected postoperative complications and longer ICU and hospital stays. In an exploratory multivariable logistic regression analysis, ERAS–PBM implementation was associated with lower odds of RBC transfusion during hospitalization (adjusted OR 0.59, 95% CI 0.36–0.98; p = 0.041). Conclusions: The integration of ERAS and PBM into a single multimodal pathway was associated with significant reductions in transfusion rates, complications, and length of stay in elective cardiac surgery. Anemia at admission and perioperative transfusion were associated with worse outcomes, emphasizing the importance of anemia management. Larger, multicenter prospective studies are warranted to confirm these results and to optimize anemia correction strategies, including earlier treatment of iron deficiency and outpatient erythropoietin use.

INTRODUCTION: The HeartMate 3 left ventricular assist device (LVAD) is an established therapy for advanced heart failure, yet contemporary real-world data from low- or medium-volume centres remain limited. We aimed to describe the characteristics, management and clinical outcomes of patients undergoing HeartMate 3 LVAD implantation at a Swiss tertiary centre. METHODS: We conducted an observational study including consecutive adult patients who underwent HeartMate 3 implantation at Lausanne University Hospital between November 2015 and January 2026. Baseline characteristics, INTERMACS profiles, perioperative data, survival and LVAD-related complications were assessed. The primary outcome was survival on LVAD support. Comparisons by LVAD indication were pre-specified exploratory analyses (destination therapy vs bridge-to-transplant). Survival analyses on LVAD support, with heart transplantation or LVAD explantation treated as censoring events, were reported. RESULTS: A total of 100 patients (mean age 58 [standard deviation 12] years, 84% male, 29% destination therapy) underwent HeartMate 3 implantation. Ischaemic heart disease was the predominant aetiology (69%) and most patients (68%) were classified as INTERMACS profiles 3–4 at implantation. Over a median follow-up of 1.5 (IQR 0.5–3) years, 27 patients died on LVAD support, corresponding to a mortality incidence rate (IR) of 13.5 deaths per 100 patient-years, while 51 patients underwent heart transplantation, corresponding to an IR of transplantation of 25.4 per 100 patient-years. Five-year survival on LVAD support was 64%, with patients censored at LVAD explantation for recovery or transplantation. LVAD-related complications included bleeding (48%), infection (50%), ischaemic stroke (12%) and right ventricular failure (39%). Survival did not differ by LVAD indication (bridge-to-transplant as reference, adjusted HR 0.62, 95% CI 0.14–2.72). CONCLUSIONS: In this contemporary, real-world, medium-sized cohort, HeartMate 3 therapy provided durable long-term support across a broad spectrum of advanced heart failure patients, with outcomes consistent with those reported in large multicentre registries.

Background and Clinical Significance: The Ozaki procedure offers excellent hemodynamics and mid-term durability, but infective endocarditis (IE), although rare, remains its most serious complication and frequently requires complex redo surgery. Sutureless valve technology, particularly the Perceval bioprosthesis, has shown value in high-risk endocarditis due to reduced annular manipulation and rapid deployment. Case Presentation: We describe the first reported case of Perceval sutureless valve implantation as a bail-out strategy for IE after a prior Ozaki procedure. A 68-year-old male previously treated with Ozaki reconstruction and LIMA-LAD bypass presented with septic and cardiogenic shock caused by Streptococcus bovis endocarditis, two years after the first surgery. TOE revealed torrential aortic regurgitation from destruction of the anterior neocuspid and large vegetations. Despite a EuroSCORE II of 89.5%, emergent redo surgery was undertaken. Redo sternotomy revealed extensive leaflet destruction and a sub-annular abscess involving two sinuses. Following radical debridement and annular reconstruction, a medium Perceval valve was implanted due to severe tissue fragility. The prosthesis seated securely with no paravalvular leakage. Conclusions: This case demonstrates that the Perceval sutureless valve can be an effective bailout option for post-Ozaki infective endocarditis, particularly when annular integrity is compromised, and conventional sutured prostheses are high risk. The combination of rapid deployment and minimal annular stress may expand therapeutic possibilities in complex redo aortic surgery.

Background: The Ozaki procedure offers excellent hemodynamics and mid-term durability, but infective endocarditis (IE), although rare, remains its most serious complication and frequently requires complex redo surgery. Sutureless valve technology—particularly the Perceval bioprosthesis—has shown value in high-risk endocarditis due to reduced annular manipulation and rapid deployment. Case Presentation: We describe the first reported case of Perceval sutureless valve implantation as a bail-out strategy for IE after a prior Ozaki procedure. A 68-year-old male previously treated with Ozaki reconstruction and LIMA-LAD bypass presented with septic and cardiogenic shock caused by Streptococcus bovis endocarditis. TOE revealed torrential aortic regurgitation from destruction of the anterior neocuspid and large vegetations. Despite an EuroSCORE II of 89.5%, emergent redo surgery was undertaken. Redo sternotomy revealed extensive leaflet destruction and a sub-annular abscess involving two sinuses. Following radical debridement and annular reconstruction, a medium Perceval valve was implanted due to severe tissue fragility. The prosthesis seated securely with no paravalvular leakage. Conclusion: This case demonstrates that the Perceval sutureless valve can be an effective bailout option for post-Ozaki infective endocarditis, particularly when annular integrity is compromised, and conventional sutured prostheses are high risk. The combination of rapid deployment and minimal annular stress may expand therapeutic possibilities in complex redo aortic surgery.

Background and Objectives: Dexmedetomidine, an alpha-2 agonist, is used as an adjunct to anesthesia in enhanced recovery after surgery (ERAS) programs. One of its advantages is the opioid-sparing effect which can facilitate early extubation and recovery. When the ERAS cardiac society was set in 2017, our facility was already using the ERAS program, in which the “fast-track Anesthesia” was facilitated by the intraoperative infusion of dexmedetomidine. Our objective is to share our experience and investigate the potential impact of intraoperative dexmedetomidine use as a part of the ERAS program on patient outcomes in elective cardiac surgery. Materials and Methods: An observational retrospective cohort study was conducted at a university hospital in Switzerland. The patients who underwent elective cardiac surgery with cardiopulmonary bypass between 1 June 2017 and 31 August 2018 were included in this analysis (n = 327). Regardless of the surgery type, all the patients received a standardized fast-track anesthesia protocol inclusive of dexmedetomidine infusion, reduced opioid dose, and parasternal nerve block. The primary outcome was the postoperative time when the criteria for extubation were met. Three groups were identified: group 0—(extubated in the operating room), group < 6 (extubated in less than 6 h), and group > 6 (extubated in >6 h). The secondary outcomes were adverse events, length of stay in ICU and in hospital, and total hospitalization costs. Results: Dexmedetomidine was well-tolerated, with no significant adverse events reported. Early extubation was performed in 187 patients (57%). Group 3 had a significantly longer length of stay in the ICU (median: 70 h vs. 25 h) and in hospital (17 vs. 12 days), and consequently higher total hospitalization costs (CHF 62,551 vs. 38,433) compared to the net data from the other two groups (p < 0.0001). Conclusions: Our findings suggest that dexmedetomidine can be safely used as part of the opioid-sparing anesthesia protocol in patients undergoing elective cardiac surgery with cardiopulmonary bypass with the potential to facilitate early extubation, shorter ICU and hospital stays, and reduced hospitalization costs.

Introduction Response to ADP P2Y₁₂ receptor inhibition by clopidogrel can be evaluated by various techniques. Here, we compared a functional rapid point-of-care technique (PFA-P2Y) with the degree of biochemical inhibition assessed by the VASP/P2Y₁₂ assay. Methods Platelet response to clopidogrel was investigated in 173 patients undergoing elective intracerebral stenting (derivation cohort n = 117; validation cohort n = 56). High platelet reactivity (HPR) was defined as PFA-P2Y occlusion time 50%. Results In the derivation cohort, receiver operator characteristics analysis for the ability of PFA-P2Y to detect biochemical HPR showed high specificity (98.4%) but poor sensitivity (20.0%) and a very low area under the curve (0.59). The VASP/P2Y₁₂ assay revealed two coexisting platelet populations with different levels of vasodilator-stimulated phosphoprotein (VASP) phosphorylation: a fraction of highly phosphorylated, inhibited platelets and another of poorly phosphorylated, reactive platelets. Analysis of the PFA-P2Y curve shape revealed different types, categorized by time of occlusion (300 seconds), and pattern (regular, irregular, and atypical). Noteworthy, curves with late occlusion and permeable curves with an irregular or atypical pattern correlated with VASP-PRI >50% and smaller sizes of the inhibited platelet subpopulation. Considering the PFA-P2Y shape of the curve for the detection of HPR improved sensitivity (72.7%) and preserved specificity (91.9%), with a rather high AUC (0.823). The validation cohort confirmed the VASP/P2Y₁₂ assay data and the usefulness of considering the PFA-P2Y curve shape. Conclusion In patients treated with acetylsalicylic acid and clopidogrel for 7-10 days, the VASP/P2Y₁₂ assay reveals two coexisting subpopulations of differentially inhibited platelets, whose relative sizes predict global PRI and distinct PFA-P2Y curve patterns, indicating incomplete clopidogrel efficacy. The detailed analysis of both VASP/P2Y₁₂ and PFA-P2Y is necessary for optimal detection of HPR. Cy.M. performed research, analyzed data, and wrote the manuscript. E.S. analyzed data and edited the manuscript. E.M.G. performed research. J.B.R. analyzed data. F.J.G. performed research. F.G. edited the manuscript. Ca.M. analyzed data and wrote the manuscript. L.A. conceived research, analyzed data, and wrote the manuscript. All authors read and approved the submitted version of the manuscript. ^* shared first authorship Received: 26 October 2022 Accepted: 03 April 2023 Accepted Manuscript online: 18 April 2023 Article published online: 07 June 2023 © 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/) Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

Heparin-induced thrombocytopenia (HIT) is a major issue in cardiac surgery requiring cardiopulmonary bypass (CPB). HIT represents a severe adverse drug reaction after heparin administration. It consists of immune-mediated thrombocytopenia paradoxically leading to thrombotic events. Detection of antibodies against platelets factor 4/heparin (anti-PF4/H) and aggregation of platelets in the presence of heparin in functional in vitro tests confirm the diagnosis. Patients suffering from HIT and requiring cardiac surgery are at high risk of lethal complications and present specific challenges. Four distinct phases are described in the usual HIT timeline, and the anticoagulation strategy chosen for CPB depends on the phase in which the patient is categorized. In this sense, we developed an institutional protocol covering each phase. It consisted of the use of a non-heparin anticoagulant such as bivalirudin, or the association of unfractionated heparin (UFH) with a potent antiplatelet drug such as tirofiban or cangrelor. Temporary reduction of anti-PF4 with intravenous immunoglobulins (IvIg) has recently been described as a complementary strategy. In this article, we briefly described the pathophysiology of HIT and focused on the various strategies that can be applied to safely manage CPB in these patients.

Vasoplegic syndrome (VS) is a common complication following cardiovascular surgery with cardiopulmonary bypass (CPB), and its incidence varies from 5 to 44%. It is defined as a distributive form of shock due to a significant drop in vascular resistance after CPB. Risk factors of VS include heart failure with low ejection fraction, renal failure, pre-operative use of angiotensin-converting enzyme inhibitors, prolonged aortic cross-clamp and left ventricular assist device surgery. The pathophysiology of VS after CPB is multi-factorial. Surgical trauma, exposure to the elements of the CPB circuit and ischemia-reperfusion promote a systemic inflammatory response with the release of cytokines (IL-1β, IL-6, IL-8, and TNF-α) with vasodilating properties, both direct and indirect through the expression of inducible nitric oxide (NO) synthase. The resulting increase in NO production fosters a decrease in vascular resistance and a reduced responsiveness to vasopressor agents. Further mechanisms of vasodilation include the lowering of plasma vasopressin, the desensitization of adrenergic receptors, and the activation of ATP-dependent potassium (K_ATP) channels. Patients developing VS experience more complications and have increased mortality. Management includes primarily fluid resuscitation and conventional vasopressors (catecholamines and vasopressin), while alternative vasopressors (angiotensin 2, methylene blue, hydroxocobalamin) and anti-inflammatory strategies (corticosteroids) may be used as a rescue therapy in deteriorating patients, albeit with insufficient evidence to provide any strong recommendation. In this review, we present an update of the pathophysiological mechanisms of vasoplegic syndrome complicating CPB and discuss available therapeutic options.

About 15 years ago, Patient Blood Management (PBM) emerged as a new paradigm in perioperative medicine and rapidly found support of all major medical societies and government bodies. Blood products are precious, scarce and expensive and their use is frequently associated with adverse short- and long-term outcomes. Recommendations and guidelines on the topic are published in an increasing rate. The concept aims at using an evidence-based approach to rationalize transfusion practices by optimizing the patient’s red blood cell mass in the pre-, intra- and postoperative periods. However, elegant as a concept, the implementation of a PBM program on an institutional level or even in a single surgical discipline like cardiac surgery, can be easier said than done. Many barriers, such as dogmatic ideas, logistics and lack of support from the medical and administrative departments need to be overcome and each center must find solutions to their specific problems. In this paper we present a narrative overview of the challenges and updated recommendations for the implementation of a PBM program in cardiac surgery.